What is the most appropriate next step in managing a 24-year-old woman, gravida (number of times pregnant) 2, para (number of viable births) 1, at 37 weeks gestation, presenting with symptoms of exhaustion, shortness of breath, bilateral pitting edema, and a systolic ejection murmur, with normal blood pressure, tachycardia, and trace proteinuria?

From the Guidelines

The most appropriate next step in management for this patient is induction of labor, as she has reached 37 weeks gestation and is experiencing discomforts of late pregnancy. The patient's symptoms, including peripheral edema, shortness of breath, and leg cramps, are consistent with normal physiologic changes of late pregnancy. However, according to the 2021 study by SaRKaR et al. 1, delivery is recommended at 37 weeks for patients with preeclampsia without severe features. Although this patient does not have a diagnosis of preeclampsia, the guidelines from the 2018 study on hypertensive disorders of pregnancy 1 suggest that women with preeclampsia should be delivered if they have reached 37 weeks’ gestation. Given the patient's gestational age and symptoms, induction of labor is a reasonable next step to alleviate her discomfort and prevent potential complications. The patient's vital signs are stable, and the physical findings (bilateral pitting edema, systolic ejection murmur) are consistent with normal cardiovascular adaptations to pregnancy. The trace proteinuria is minimal and not concerning in the absence of hypertension. The patient should be counseled about the risks and benefits of induction of labor and monitored closely for any signs of complications during the induction process. It is essential to note that the decision to induce labor should be made on a case-by-case basis, taking into account the patient's individual circumstances and medical history. In this case, the patient's symptoms and gestational age suggest that induction of labor is the most appropriate next step in management.

From the Research

Assessment and Management

The patient is a 24-year-old woman, gravida 2 para 1, at 37 weeks gestation requesting induction of labor due to discomfort and various symptoms. The symptoms include exhaustion, shortness of breath, bilateral foot and ankle swelling, difficulty sleeping, and bilateral crampy pain in her calves.

Evaluation of Fetal Well-being

Given the patient's symptoms and gestational age, evaluation of fetal well-being is crucial before making any decisions regarding induction of labor. The provided studies discuss various methods of antepartum fetal surveillance, including:

• Nonstress test
• Contraction stress test
• Biophysical profile

These methods are used to assess fetal well-being and identify potential complications. According to 2, 3, 4, the biophysical profile allows for a more thorough evaluation of fetal well-being and can significantly reduce the false-positive rate of the nonstress test/contraction stress test.

Next Steps in Management

Considering the patient's request for induction of labor and the importance of evaluating fetal well-being, the most appropriate next step in management would be to perform a biophysical profile or other antepartum fetal surveillance tests to assess the well-being of the fetus. This is supported by studies such as 5, which compared the fetal biophysical profile score and the nonstress test in high-risk pregnancies.

Key Considerations

• The patient's symptoms, such as exhaustion and shortness of breath, should be taken into account when evaluating her overall health and well-being.
• The presence of symmetric, bilateral pitting edema and a 2/6 systolic ejection murmur should be considered in the patient's management plan.
• The patient's urinalysis showing trace protein should also be taken into account, as it may indicate potential complications.

Note: The study 6 is not directly relevant to the patient's situation, as it discusses infusion therapy standards of practice updates.